Breastfeeding Support Groups in Tajikistan

Uma Palaniappan and Zinaida Abdullaeva

Uma Palaniappan & Zinaida Abdullaeva

Uma Palaniappan is the Nutrition Programme Manager of Action Against Hunger in Kurgan Tyube in Tajikistan. She has a doctoral degree in nutrition and has been working in Tajikistan for the past year.

Zinaida Abdullaeva is the Programme Officer for the Breastfeeding Support Group and Health Education programme. She is a paediatrician and has been working with Action Against Hunger in various capacities since 2002.

Mothers gathered at a Breastfeeding Support Group

The authors would like to acknowledge the support of midwives of Kurgan Tyube and Kulyab who are actively involved with the women in the BFSGs. The authors are also grateful to the local medical house staff for their continuous support of our activities. We also acknowledge the support of Shakhnoza Muminova, Head of Mission and Sanjay Rimal, Nutrition Programme Manager of Kulyab. We are especially grateful to the support of Marie Sophie- Simon, Nutrition Programme Coordinator in HQ who is always willing to help and guide us.

This field article describes Action Against Hunger's experiences with Breastfeeding Support Groups in Tajikistan, set up to address the poor nutritional status in infants and young children reflected in their nutrition surveys and feeding centre admissions, and using knowledge, attitudes and practices survey to inform the programmes development.

Action Against Hunger - Tajikistan mission activities in breastfeeding support groups

Tajikistan is a land-locked mountainous country of 143,100 sq/km, situated in central Asia and is bordered by Afghanistan, China, Uzbekistan and Krygystan. The country is divided into 4 oblasts, namely, the Regions of Republic Subordination (RRS) in the centre, Khatlon in the south, Sughd in the north, and GBAO/Badakhshan in the east. It is a largely rural country, where two-thirds of the population works in the agricultural sector.¹ Tajikistan is principally dependent on cotton as the main crop of cultivation. The agricultural industry suffers from lack of modernisation. Furthermore, the land reforms have limited the land left over for cultivation and diversification.²

With the collapse of the Soviet Union in 1991, the country faced civil war in the 1990s. The peace accord in 1997 helped improve the security situation, but the country continues to face slow economic development. Tajikistan is the poorest of the five Central Asian Republics. It is estimated that 64% of the population lives below the poverty line³ and that 20-33% of the population falls under the 'extremely' poor category.⁴ Since 2002, the government has been committed to a Poverty Reduction Strategy resulting in a reduction of poverty of 19%.⁵ Although macro-economic indicators are improving, the household level situation remains precarious. Unemployment rate is estimated to be around 40%⁶ while migration of skilled and unskilled workers to Russia and other neighbouring countries in search of better opportunities is common.

Additionally, lack of investment in and maintenance of the country's infrastructure has severely affected the efficient running of several vital social services. The health sector faces various challenges including shortages in public financing and migration of skilled medical personnel. It is also plagued by lack of modernisation. Access to several basic social services, such as water and sanitation and education, has been limited due to a lack of essential supplies and proper maintenance.

Malnutrition rates

The total population is reported to be 6.4 million (UNICEF, 2004) and according to the 2000 census, under five children comprise 17.4 % of the total population. The infant mortality in 2003 was estimated to be at 65 per 1000 live births, while the under-5 mortality rate was 79 per 1000.⁷ Additionally, several surveys have assessed the nutritional status of children. In the period prior to 2005, persistently high rates of acute malnutrition were reported in the Khatlon region. The 2005 national nutrition survey, although indicating a lower prevalence of global acute malnutrition (GAM) compared to 2004, is still higher compared to 2003 (see Table 1 below).⁸ In 2006, the overall rate of GAM in Tajikistan was reported to be 7%.⁹ Thus, although the overall situation in Tajikistan appears to be improving, our programme activities and surveys, which will be discussed in detail in the following sections, indicate that there remains much work to be done to enhance health and nutrition knowledge and practices of women in order to improve nutritional status of children.

There are several reasons for the poor nutritional status seen among children less than 5 years old. These include household food insecurity and micronutrient deficiencies¹⁰ and poor childcare and nutritional practices. For example, infants are introduced too early to poor nutritional value foods and only 25.5% of infants are exclusively breastfed.¹¹ Mothers stop breastfeeding for several reasons including work pressures and the need to care for families.⁴ Furthermore, from the age of six months onwards, infants are often fed the same foods as adults, including sweetened tea and bread.

Knowledge, Aptitude and Practice Survey

Poor nutritional practices and their consequences are observed by AAH staff and reflected in surveys. About one quarter of the children admitted to the AAH-managed Therapeutic Feeding Centres (TFCs) in Tajikistan are less than 6 months of age. Mothers accompanying these infants are supported to re-lactate in order to provide the infants with the best source of nutrition. Furthermore, the levels of malnutrition among children 6-29 months are consistently higher than other target age groups.¹² This is the age when children increasingly rely on complementary foods. Our work with rural women suggested that women were facing significant breastfeeding and complementary feeding difficulties. In order to obtain more information on these difficulties, we conducted a baseline KAP survey (Knowledge, Aptitude and Practice) on breastfeeding and complementary feeding practices in 10 districts of Khatlon Oblast in 2004.

The 2004 KAP survey indicated that although almost all (99.6%) women reported having breastfed their children, nearly 72% of women reported giving tea to their babies within the first 6 months of life. However, 89% of women reported that breastmilk is the best food to give to infants less than 6 months of age. There is thus a failure to link knowledge with actual practice in breastfeeding. Furthermore, the survey found that women wanted breastfeeding support groups to further their knowledge on appropriate breastfeeding and complementary feeding practices. Thus, KAP survey recommendations included:

• Implementation of Breastfeeding Support Groups in the surveyed villages.
• Provision of education on breastfeeding, complementary feeding, and specific nutrition and health and hygiene messages.

Breastfeeding Support Groups (BFSG)

In response, AAH established Breastfeeding Support Groups (BFSGs) at a local level, where it is easier for women to seek support. These groups aim to educate mothers, women of childbearing age, young girls and grandmothers on the benefits of breastfeeding infants and young children. Mothers-in-law are encouraged to participate in the groups, as they have a significant influence on young married women.

AAH Tajikistan currently operates 25 BFSGs in eight districts in Kurgan Tyube and Kulyab provinces of Khatlon region of Tajikistan. (19 BFSGs under an ECHO funded project and 6 BFSGs under CIDA funded project). The BFSGs are supported by a BFSG and Health Education Programme Officer and five midwives. They work in collaboration with local medical house staff. Each village has two BFSG rooms. The groups meet on a regular basis each week, with regular ACF support staff visiting 2-4 times per month, depending on the group's requests.

In addition to breastfeeding and complementary feeding topics, the midwives also conduct health education on other subjects of importance to pregnant and lactating women, such as nutrition, anaemia, water borne diseases, respiratory tract infections, immunisation, iodine deficiencies, child care, intestinal parasites, family planning and HIV/AIDS. The midwives are also equipped with materials to conduct cooking demonstrations of appropriate complementary foods. Health education materials that are nationally approved are used to ensure coherence of messages coming from the Ministry of Health and other non-governmental organizations (NGOs).

From January and February 2006, gardening education was included as a component of BFSG activities. This is conducted by an ACH agronomist. Overall, 539 women have attended the training sessions so far. The agronomist conducts education on the importance of fruits and vegetables, methods of land preparation for planting vegetables, choosing the best seeds, harvesting and preservation methods. Seeds and tools are also distributed to regular participants.

The midwives conduct regular home visits to all newly delivered mothers and other women who are unable to attend the regular meetings or who have difficulties with breastfeeding. The midwives tend to be flexible depending on the seasons. For example, during the cotton season (May to November), most women spend a considerable part of their days in the cotton fields. Therefore the midwives meet with the women in the fields in order to conduct short meetings while they gather for the weighing of the cotton.

There are at least two active women in each village who promote the activities of the breastfeeding groups among village women. The group leaders are mainly nurses and laywomen from the village. They actively participate in each session by helping to identify women in the villages who are pregnant and women who have difficulties in breastfeeding or complementary feeding.

The 2004 KAP survey indicated that more than half of the women were taught to breastfeed by a medical person (55%). This finding reinforces the need for medical staff to be upto- date with breastfeeding knowledge and to know how to support appropriately those women who are having difficulties with breastfeeding. With this objective in mind, the BFSG Programme Officer conducts training/refresher training of medical staff in local health structures in areas where the BFSG rooms are located.

One of the objectives of the BFSG programme is to promote local capacity building. The active lay-women are also being trained by the midwife on health education topics. The objective is to enable the volunteers to continue the breastfeeding support group activities on their own in order to ensure sustainability of the programme once ACF phases out its activities in Tajikistan. There are currently 54 volunteers working in Kulob and Kurgan Tyube BFSG villages.

In partnership with the Ministry of Health and local maternity houses, ACH has played an active role in the World Breastfeeding Week celebrations held each year in August. Additionally, Health Days are conducted where women already trained in the breastfeeding groups are encouraged to conduct theatre plays, present songs, and demonstrate healthy food choices to promote breastfeeding and health and hygiene messages.

Since 2005, more than 7,400 women have regularly attended the BFSGs. There are many success stories that are encouraging (see case studies). The current situation in Tajikistan is no longer considered to be an emergency. Therefore the focus of ACF programmes tends towards local capacity building and preventive measures. BFSGs play a vital role in both promoting health and preventing malnutrition among children less than 5 years and are working well. The KAP survey, planed for the first quarter of 2007, will show what level of improvement in knowledge and practice of breastfeeding and complementary feeding practices among women has taken place. It is hoped that the medical staff and active women trained in promoting breastfeeding and appropriate complementary feeding and health and hygiene practices will continue their important work in the future.

For further information, contact Marie Sophie-Simon, AAH USA, email: mss@aahusa. org

Success stories

In Hosilot village in Kholkozobod, a young woman, soon after delivery, found her breasts swollen and painful. Her mother, mother-in-law and relatives advised her to warm her breasts with salt and to stop breastfeeding her newborn, as the milk would not be good. However, the woman, who had already attended our BFSG sessions, simply asked for a syringe and expressed her breastmilk into a cup. When her breasts became soft, she asked her mother to get her baby. She then gave the expressed milk to the infant using the syringe. She did the same for the second breast. Other relatives in the room were surprised as this was the first time they had seen a mother expressing breastmilk. Her mother and mother-in-law were proud and happy for her.

In Alauddin village of Farhor district, two BFSG participants were admitted at around the same time to the Farhor Central Maternity hospital for delivery. The first woman who delivered had no problems during her delivery, while the second woman underwent caesarean to deliver her child. As she was not strong enough, she remained in the recovery department while her newborn baby was transferred to the new babies ward and started on formula milk. When the first woman found out that the nurse was feeding the baby of the second woman with formula milk, she asked the nurse to stop feeding the child with formula milk, saying that she knew the economic condition of the other woman and she would not be able to afford formula milk. Instead she offered to breastfeed the infant herself. She convinced the staff that she had enough milk to feed her own child and the other woman's child. She further explained about ACF midwife's advice on the importance of breastfeeding. The staff were surprised at her knowledge and her willingness to feed another woman's child. After obtaining the permission of her husband, she started feeding the other baby as well. The second mother, after recovery from surgery, felt sick and uneasy due to pain in her breasts. She was aware of possible problems because of the knowledge she gained at the BFSG sessions. So with the help of the staff nurse, she expressed her breastmilk, which she then fed to her baby. At the same time she was relieved from the pain. Both women are continuing to breastfeed their children.

¹ Action Against Hunger Report, 2003. Land Reform in Tajikistan: From the Capital to the Cotton Field.

² UNICEF. Conference Report. 2004. The Situation of Mother and child Health in Tajikistan.

³ UNDP Human Development Report, 2004

⁴ Falkingham J et al, 2002. A Profile of Poverty in Tajikistan. London School of Economics and World Food Program. Precrop Assessment Mission Report and Cereal Yield Forecast for 2002; Tajikistan, Dushanbe, WFP.

⁵ 83% in 1999 against 64% in 2003

⁶ ICG Asian Report No.51, 2003. Tajikistan: A Roadmap to Development.

⁷ Multiple Indicators Study, 2006. Findings from Tajikistan, Preliminary Findings Report

⁸ AAH nutrition in Khatlon in 2005, AAH-MoH NNS 04, AAH and consortium of NGOs NNS 03

(footnote 9 missing)

¹⁰ UNICEF, The situation of mother and child health in Tajikistan

¹¹ National Nutrition Survey, 2006. A Study of the nutritional status of children aged 6-59 months and reproductive women in four regions (Oblasts) of Tajikistan

¹² Action Against Hunger Nutrition Survey, 2004.